Provider Demographics
NPI:1730399494
Name:ROMAN, MANUEL DE JESUS (MD)
Entity type:Individual
Prefix:DR
First Name:MANUEL
Middle Name:DE JESUS
Last Name:ROMAN
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:BO. CARRERAS
Mailing Address - Street 2:CAR. 405 KM 2.4
Mailing Address - City:ANASCO
Mailing Address - State:PR
Mailing Address - Zip Code:00610
Mailing Address - Country:US
Mailing Address - Phone:787-806-8347
Mailing Address - Fax:
Practice Address - Street 1:BO. CARRERAS
Practice Address - Street 2:CAR. 405 KM 2.4
Practice Address - City:ANASCO
Practice Address - State:PR
Practice Address - Zip Code:00610
Practice Address - Country:US
Practice Address - Phone:787-806-8347
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-23
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PR6927302R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes302R00000XManaged Care OrganizationsHealth Maintenance Organization
Provider Identifiers
StateIdentifier IDID TypeIssuer
PRS94-500Medicare ID - Type Unspecified